Individualising the recovery process through eHealth
Authors: Elias A Chamely, Lillian S Kao
Journal: The Lancet Digital Health (2023)

Enhanced recovery after surgery (ERAS) protocols have reduced rates of postoperative complications, shortened lengths of hospital stay, decreased health-care costs, and hastened functional recovery for patients. In doing so, ERAS has shifted the onus of postoperative recovery predominantly to the home setting. Although ERAS protocols standardise processes of care in the immediate perioperative period, there is a scarcity of evidence-based guidelines to direct a patient's resumption of normal physical activity beyond ambulation after abdominal surgery.1van Vliet DC van der Meij E Bouwsma EV et al.A modified Delphi method toward multidisciplinary consensus on functional convalescence recommendations after abdominal surgery.Surg Endosc. 2016; 30: 5583-5595Crossref PubMed Scopus (37) Google Scholar Furthermore, although registries are starting to collect patient-reported outcomes, there is a paucity of data to guide benchmarking of surgical outcomes other than 30-day morbidity and mortality.2Liu JB Pusic AL Matroniano A et al.First report of a multiphase pilot to measure patient-reported outcomes in the American College of Surgeons National Surgical Quality Improvement Program.Jt Comm J Qual Patient Saf. 2019; 45: 319-328Summary Full Text Full Text PDF PubMed Scopus (18) Google Scholar The study by den Bakker and colleagues3den Bakker CM Schaafsma FG Consten ECJ et al.Personalised electronic health program for recovery after major abdominal surgery: a multicentre, single-blind, randomised, placebo-controlled trial.Lancet Digit Health. 2023; (published online July 5)https://doi.org/10.1016/S2589-7500(23)00084-5Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar in The Lancet Digital Health investigated how a personalised electronic health (eHealth) programme could be utilised to help patients return to normal activities after abdominal surgery. In this multicentre randomised, placebo-controlled trial, conducted at 11 teaching hospitals in the Netherlands, standard care alone was compared to standard care plus a personalised postoperative eHealth intervention. This study was done in adult patients undergoing major abdominal surgery, defined as laparoscopic or open colectomy or hysterectomy.3den Bakker CM Schaafsma FG Consten ECJ et al.Personalised electronic health program for recovery after major abdominal surgery: a multicentre, single-blind, randomised, placebo-controlled trial.Lancet Digit Health. 2023; (published online July 5)https://doi.org/10.1016/S2589-7500(23)00084-5Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar The intervention provided patients with resources to facilitate goal attainment; patients received an activity tracker and were given access to an eHealth website and mobile app that allowed for interactions with their health-care provider via an electronic consultation (eConsult) function. The control group had access to a placebo website with generic postoperative information. The primary outcome was return to normal activities (defined as the time from surgery to resumption of eight targeted activities), preselected by each patient from the Dutch Patient Reported Outcomes Measurement Information System Physical Function (PROMIS-PF) item bank; the 29 possible activity choices each had a comparable level of difficulty. Patients were surveyed at pre-planned time intervals during a 12-month follow-up period. In the intention-to-treat analysis, the median time until return to normal activities was 52 days (IQR 33–111) in the intervention group compared with 65 days (39–152) in the control group (adjusted hazard ratio 1·30 [95% CI 1·03–1·64]; p=0·027). These results were similar in the per-protocol analysis. This trial builds on previous work done by members of this study group4van der Meij E Anema JR Leclercq WKG et al.Personalised perioperative care by e-health after intermediate-grade abdominal surgery: a multicentre, single-blind, randomised, placebo-controlled trial.Lancet. 2018; 392: 51-59Summary Full Text Full Text PDF PubMed Scopus (58) Google Scholar, 5Vonk Noordegraaf A Anema JR van Mechelen W et al.A personalised eHealth programme reduces the duration until return to work after gynaecological surgery: results of a multicentre randomised trial.BJOG. 2014; 121 (discussion 1136): 1127-1135Crossref PubMed Scopus (54) Google Scholar, 6Bouwsma EVA Huirne JAF van de Ven PM et al.Effectiveness of an internet-based perioperative care programme to enhance postoperative recovery in gynaecological patients: cluster controlled trial with randomised stepped-wedge implementation.BMJ Open. 2018; 8: e017781PubMed Google Scholar and increases the generalisability of their eHealth intervention to patients undergoing other surgical procedures and those with malignant disease. The intervention is novel since it focuses on enhancing task performance or goal attainment rather than on goal achievement, and it creates personalised recovery plans based on what outcomes matter the most to patients. Additionally, the results of this trial argue for tracking of longer-term (>30 days) patient-reported outcomes. No deaths were reported, and only 5% of patients had serious complications (defined as those with a Clavien-Dindo score >3). Thus, collecting patient-reported outcomes as a quality metric will become even more important as clinical outcomes after major abdominal surgery continue to improve. Despite the excellent clinical outcomes, time to return to normal activities varied widely in both groups (as represented by the IQRs), suggesting opportunity for improvement. The generalisability of these findings still requires further validation. Only 38% of eligible patients consented to participate in the study. Reasons for refusal were not provided; however, given that 89% of participants completed the final survey, one possibility is that patients who were already more motivated consented to participate. No data were provided about the health or computer literacy of patients, but the majority (79%) of participants had a medium (completion of secondary school) or high (professional education or university) level of education. Other social determinants of health, which have been linked to survivorship after cancer, might also influence the effectiveness of the intervention or its implementation, or both, in other populations.7Coughlin SS Social determinants of health and cancer survivorship.J Environ Health Sci. 2021; 7: 11-15PubMed Google Scholar For example, only 9% of trial participants were unemployed or incapacitated for work, and presumably all participants were insured given the universal requirement for health insurance in the Netherlands. Factors such as housing insecurity, food insecurity, and inadequate social support might also lessen the impact of the intervention or increase the difficulty of its implementation. Given that ERAS protocols have been shown to reduce in-hospital disparities in outcomes such as length of stay,8Wahl TS Goss LE Morris MS et al.Enhanced Recovery After Surgery (ERAS) eliminates racial disparities in postoperative length of stay after colorectal surgery.Ann Surg. 2018; 268: 1026-1035Crossref PubMed Scopus (90) Google Scholar care must be taken to ensure that interventions to enhance post-discharge recovery do not result in worsening disparities. The authors should be commended for a well-conducted trial that provides important information for counselling patients about their expected postoperative recovery goals. As technology continues to evolve, including artificial intelligence, the ability to harness eHealth to enhance post-discharge recovery will only continue to improve. However, surgeons need to ensure that incorporating eHealth into routine care does not worsen existing health-care disparities and that personalised recovery considers not just what matters the most to patients but also what resources are available to them. We declare no competing interests. Personalised electronic health programme for recovery after major abdominal surgery: a multicentre, single-blind, randomised, placebo-controlled trialThis eHealth programme, delivering personalised care based on goal attainment scaling, enabled patients to return to their normal activities 13 days earlier than those who received standard care. Full-Text PDF Open Access